Subjective Assessment of the Shoulder

Original Editor - Carin Hunter based on the course by Ian Horsley
Top Contributors - Jess Bell, Ewa Jaraczewska, Carin Hunter, Tarina van der Stockt, Kim Jackson and Robin Tacchetti

Introduction

The subjective examination is often undervalued in the assessment and management of patients. It is, however, a crucial aspect of the examination as it determines the severity, irritability, and nature of the patient's condition. Good questioning leads to the formation of a primary hypothesis, possible methods of treatment, and potential prognosis of the injury. This page discusses the subjective examination of the shoulder, but much of the information presented can be applied to the subjective assessment of any part of the body.

Developing Rapport

The following tools can be used during the subjective assessment to help the therapist develop a rapport with the patient:

• The first impression
  • Make sure you are prepared and ready to receive your patient
• Face the patient
• Explain that you will be taking notes during the interview, but that you will be listening to them in between
• Make sure you have open body language
• Do not interrupt the patient
  • Interrupting the flow of a patient's dialogue can prevent them from giving you important information
  • It takes patients approximately 92 seconds to explain their problem if not interrupted
  • Clinicians have been found to be seven times more likely to interrupt than patients

Useful Techniques

When gathering information, there are a few tools that you can utilise to make your task easier:

• Ask open-ended questions:
  • This gives the patient a chance to provide detailed answers
  • Mind the gap - leave gaps for the patients that they feel they need to fill
• Summarising:
  • This helps to ensure that the physiotherapist has obtained the correct version of the events, facts, and the perception of the patient. It provides the patient with an opportunity to clarify aspects of history, make amendments to the clinician's understanding of the patient's condition, as well as to further elaborate on an element which may have been overlooked. Essentially, it helps therapists to ensure that they are on the same page as patients and that they know what the primary requirements of the patients are from this consultation.

Biopsychosocial Approach

The contents of the subjective examination have traditionally focused on the biomedical, biomechanical and pathoanatomical factors. This way of questioning can, however, limit the clinician's understanding of the patient's unique experience.

The biopsychosocial model was first conceptualised by George Engel in 1977. This model suggests that to understand a person's medical condition, it is important to not only consider the biological factors, but also the psychological and social factors:

• Bio (physiological / pathology features)
• Psycho (thoughts, emotions and behaviours such as psychological distress, fear / avoidance beliefs, current coping methods and attribution)
• Social (socio-economical, socio-environmental, and cultural factors suchs as work issues, family circumstances and benefits / economics)

This model implies a patient-centered approach. Clinicians need to determine how the problem impacts on the patient's lifestyle and how the patient's lifestyle affects their problems. It is imperative that clinicians understand that the subjective interview is not merely a series of questions, but the process of building a relationship with the patient.

Shoulder Specific Considerations

When conducting the subjective interview there are a few key pieces of information / examples that patients may use / give that can provide the therapist with clues as to what the diagnosis could be. Throughout the examination, therapists can rule in and rule out conditions as they generate a hypothesis. And at the end of the subjective examination, therapists should have an idea of the top three areas on which to focus their examination. In the shoulder, certain features of the subjective history may point towards specific conditions:

• Acromioclavicular joint
  • Pain while putting on seatbelt and getting dressed
  • Pain with cross-body movement
• Long head biceps
  • Pain with elbow flexion
• Subacromial pain
  • Pain in all directions, rather than one specific direction
• Rotator cuff
  • Pain tends to be more specific and with repeated movements
• Labrum
  • Patients may describe catching or clicking
• Anterior capsule
  • Feeling of anterior instability
• Humeral head problems
  • Crepitus
• Referred pain from cervical spine
  • Pain with cervical spine movements
• Referred visceral pain
  • Consider the skin or eyes, general health, or if pain appears to be related to food etc

History

An accurate history should include the pain characteristics. Examples of some important questions and points to cover in relation to the shoulder are listed below:

• Has there been stiffness in the shoulder or instability?
• Have there been any functional impairments?
• Has there been any trauma?
• Does they get any aches and pains in any other joints, either in the same limb or elsewhere in their body?
• Do they have neck pain?
• Have they got any systemic or neurological symptoms?
• Is their pain related to their occupation or sporting activities?
• Are they on any medication and could that medication be influencing some of their pain?
• Have they had previous musculoskeletal problems?
• Do they have a history of malignancy?
• What is their general health like?
• Are there other co-morbidities that could be affecting their pain?

Red Flags

Some red flags to consider are:

• Arthritis
• Pain and weakness
• Sudden loss of ability to actively raise their arm
• Muscle swelling
• Red skin
• Painful joint
• Fever
• Systemically unwell
• Trauma leading to a loss of rotation
• Abnormal shape
• Possible shoulder dislocation, which could sometimes be missed
• New symptoms of inflammation in several joints (raises suspicion of inflammatory arthritis)
• Malignancy
• Referred pain from the neck, heart or lungs
• Polymyalgia rheumatica
• Haemiplegic shoulder

Other Tests to Consider

An x-ray should be considered if:

• There is a history of trauma
• There is little improvement with conservative treatment
• Symptoms last for more than four weeks
• There is severe pain or restriction of movement

Blood tests should be performed if any of the following are suspected:

• Malignancy
• Polymyalgia rheumatica
• Inflammatory arthritis
• Patients ought to be tested for diabetes if they present with a frozen shoulder

Social Determinants of Health

An important factor when assessing the shoulder is to consider the social determinants of health. Social determinants of health are an underlying cause of today’s major societal health dilemmas including obesity, heart disease, diabetes, and depression. Moreover, complex interactions and feedback loops exist among the social determinants of health.

Examples of social determinants of health include:

• Income level
• Educational opportunities
• Occupation, employment status, and workplace safety
• Gender inequity
• Racial segregation
• Food insecurity and inaccessibility to nutritious food choices
• Access to housing and utility services
• Early childhood experiences and development
• Social support and community inclusivity
• Crime rates and exposure to violent behavior
• Availability of transportation
• Neighborhood conditions and physical environment
• Access to safe drinking water, clean air, and toxin-free environments
• Recreational and leisure opportunities

Because of health screening, it is possible for the clinician to act upon the outcomes associated with the above factors. Once a problem has been identified, patients can be referred on to the appropriate services.

Other Considerations

It is also important to consider smoking, and waist circumference and waist to hip ratio. These factors have all been shown to have an effect on the prevalence of shoulder pain. Smoking is associated with rotator cuff tears, shoulder dysfunction, and shoulder symptoms. It may also accelerate rotator cuff degeneration and increase the prevalence of larger tears. Similarly, it may increase the risk of symptomatic rotator cuff tears, which increases the need for surgical intervention.

Shoulder Physical Examination

The shoulder physical examination should include inspection, palpation, active and passive movements, as well as a check of the patient's neck, arms, axilla and chest for referred pain. A neurological examination may also be appropriate. A more detailed assessment of the objective assessment is to follow.